Palo Alto Weekly

Picture this

An illustrator and a surgeon help doctors, patients see the latest in medical techniques

by Rebecca Wallace

Chris Gralapp is intimately familiar with a world she can never visit. She has followed the path of the Eustachian tube, navigated the spirals of the cochlea.

Her colored pencils fuel her travels, flying her into the landscape of the inner ear, through the miniature universe inside the skull. It's as if she were a tiny person standing inside, marveling at the curves and canals.

As a longtime medical illustrator, Gralapp has collaborated with many physicians. One of the most frequent copilots on her journeys is surgeon Robert K. Jackler, chair of the Department of Otolaryngology — Head and Neck Surgery at Stanford University School of Medicine. The pair has been a most productive team, creating illustrations that bring viewers inside complex procedures, such as treating hearing loss by placing an infinitesimal prosthesis inside the ear.

Jackler is married to an artist, Laurie Jackler, but he admits he can't draw too well. He relies on Gralapp's hand to help make what he sees during surgery clear and vivid to others. Their illustrations, CD-ROMs and books — including the "Atlas of Skull Base Surgery and Neurotology" — serve as valuable aids for doctors honing their techniques, residents learning to be fully fledged surgeons, and patients yearning to understand the work that will be done inside their own bodies.

"On the face of it, you really don't see art and science being a marriage," Gralapp says recently in Jackler's Stanford office. "But we're doing the same thing, just in different ways. We're trying to explain the world."

As an educator, Jackler clearly sees merit in endeavoring to explain the world to as many people as possible.

"As a doctor, you can help thousands of patients," he says. "If you can create an educational tool to help doctors all around the world, you can help millions."

The pair has put hundreds of their illustrations online, which means a surgeon on the other side of the world could be consulting one in an operating room right now.

Gralapp and Jackler are also continuing a tradition that exists in many lands and goes back countless years, Gralapp says. "The great anatomists of the Renaissance all had an illustrator by their side."

This contemporary collaboration takes place surrounded by ears.

Gralapp, who lives in Marin County, regularly comes to Jackler's Stanford workplace. She's so familiar with human anatomy that she doesn't need to observe in the operating room anymore, so the pair work in the office, in the company of antique medical drawings of ears. Curving like seashells, the ears watch from wooden frames on the wall.

On a low table, colored pencils fill a white School of Medicine mug. Pieces of tracing paper show two key parts of the collaboration process: two rather ragged preliminary sketches by Jackler, next to a more finished version by Gralapp.

"Any sketch I do is dead flat," Jackler says affably. "She can create that dimensionality."

This is a now-familiar process. Jackler comes in with an idea and his sketches, often along with MRI or CT images, and Gralapp works with him to create a formal, colorful incarnation. Her drawings are scanned into the computer, and the two refine the illustrations there. (In years past, Gralapp used watercolor, but the computer has replaced that.)

The illustrations are often bright with false colors. While some hues are standard (arteries are red, veins are blue), it's not uncommon to see a fetching green or purple.

"We try to maintain consistency ... but we sometimes use different colors to show adjacent structures with different purposes," Jackler says.

Jackler and Gralapp seem to have a friendly working rapport and speak each other's artistic language. It helps that Gralapp knows her anatomy.

"She's become a master of head and neck, which is the most Byzantinely complex area," Jackler says. "She now knows the ear any which way you can imagine."

From time to time, other physicians who do projects with Gralapp will come in to watch her work with Jackler, to learn from their process, Jackler says.

Peter Hwang, who also works in otolaryngology at Stanford, echoes Jackler's praise. He recently finished a textbook on sinus surgery, with Gralapp doing 100 illustrations.

"The process of creating new art with Chris was collaborative and organic," Hwang said. "For example, Chris was trying to get the shading just right on a complex anatomic perspective, so she went home and cut an apple to study how light and shadow fell on the cut fruit. Needless to say, she brought this insight into her drawing, and nailed it."

Hwang also sees Gralapp as an excellent educator. "She recognizes that her drawings are created to teach, and she knows how to distill the essence of the teaching points into a natural, clear and accurate depiction of the human anatomy. So the collaboration extends beyond the lines and colors of the drawing towards something bigger — allowing us as educators to be more effective teachers through her beautiful work."

There is, of course, something to be said for creating beauty for beauty's own sake. Gralapp clearly pays attention to aesthetics in the elegant simplicity of her lines.

But attractive anatomical drawings have been made many times over the centuries. Jackler is more interested in illustrating new, complex procedures.

"We specialize in taking on these things that other people don't," he says.

One focus has been cranial-base surgery, as seen in Jackler's "Atlas of Skull Base Surgery and Neurotology," published in 2008 with 700 color illustrations by Gralapp. The book details what the tumors are and how they grow, as well as methods to remove them, many of which had not been developed as recently as 30 years ago.

"Now we can make tunnels through the ear and other places to get to intercranial tumors that were previously unreachable," Jackler says.

Another project is the pair's work with the Stanford Initiative to Cure Hearing Loss. Researchers have been focusing on trying to cure deafness through regenerative methods, such as stem-cell therapy using the patient's own skin cells.

Jackler cites hair-cell regeneration as an example: Hearing loss often takes place when hair cells in the cochlea are damaged. Jackler flips through illustrations depicting the damaged sensory epithelium, and how stem cells from the patient's skin or fat might be placed in the cochlea to fuse with the structures and then develop as hair cells.

Gralapp's drawings depict the process in a straightforward way, with economical use of lines and color. It's just as important to leave out what is not needed, she notes.

Since the procedure is not yet done on patients, this illustration process is aimed at a different audience: potential donors.

"It's an exciting project, but it needs money," Jackler says.

The pair chats about a recent donors' meeting where they presented their illustrations.

"Do you think they got it?" Gralapp asks.

Jackler smiles. "Definitely."

How does it feel for this artist to be involved with what could be a major treatment for hearing loss?

"It's so exciting," Gralapp says. "I feel very honored and humbled to be a part of it."

In some cases, the pair does create purely anatomical drawings. With the ear, they felt compelled to correct the record.

For years, many people relied on an intricate drawing of the ear done by the pioneering medical illustrator Max Brödel (1870-1941). But it wasn't completely accurate, Jackler says: It has the wrong number of turns in the cochlea, for example, and the anvil is reversed.

"Although it was brilliant at the time, it has huge errors," Jackler says. So he and Gralapp made a new one with the aid of modern imaging systems. "We created drafts and circulated them around the world and asked for feedback."

Now the finished product is prominently displayed on Gralapp's laptop, the cochlea glowing pale green and the external ear a vivid, healthy pink.

Gralapp and Jackler started collaborating in the '80s at the University of California at San Francisco, where she earned her master's degree in medical and biological illustration and he was a resident. Jackler was at UCSF for 20 years and has now been at Stanford for eight.

Gralapp has built her own biomedical-visualization business, focusing on matters of the head and neck and facial plastic surgery, for academic, legal and industry clients such as Genentech, Scientific American, and various UC campuses.

She has also done animal illustrations for the Smithsonian Institution, depicted bariatric surgery for World Book and created artwork for a series of children's games about the brain. Outdoors, she draws rock art for national, state and local parks.

Gralapp says one of the most rewarding aspects of her job is feeling that she's easing the anxiety and fear of medical patients.

"Patients are a vulnerable population. I want to show them something nonthreatening," she says. "You can't scare them with surgical photographs. They'd turn and run."

Gralapp breaks into a gentle smile as she recalls a recent presentation she gave about her work to a group of about 30 patients. They had been through the illustrated medical procedures and were there to give input to Gralapp for improving her work.

"The gratifying thing is, they got what I was showing," she says. "They helped keep me on track. It was wonderful."

Meanwhile, Jackler continues to pursue a favorite side project: a Stanford research group studying the effects of tobacco advertising. It grew out of his collection of thousands of vintage cigarette ads, and a traveling exhibition of them, curated by his wife.

Jackler has donated his collection to the Smithsonian, but several reproductions of the images decorate his office. A poster from Canada's Tobacco Fund is prominently displayed. A soldier lights up beneath the slogan "Our Boys Want Smokes."

"It's been an interesting process for an ear doctor to become a tobacco guy," Jackler says.

He's also taught at Stanford Continuing Studies on making sense of the human senses. Right in line with his illustration work, he's got another idea for a class up his sleeve: "I want to do a glimpse into surgery for non-medical people."

Info: Several of Chris Gralapp's illustrations of skull-base surgery and neurotology are posted at med.stanford.edu/ohns/atlas_sb/. The artist's own website is chrisgralapp.com. Information about the Stanford Initiative to Cure Hearing Loss is at hearinglosscure.stanford.edu.